Name: endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas
Uploaded: 2018-01-17T10:40:00
Description: Watch this Scientific Journal Video about Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas at JoVE.com

Gostaríamos de agradecer a unidade de Endocrinologia e a equipe da sala operativa para sua ajuda e apoio na gestão destes pacientes. Não temos nenhuma fonte de financiamento para este trabalho, nem conflito de interesses.

O protocolo aqui ilustrado segue as diretrizes do Comitê de ética pesquisa humana no Hospital da Universidade de Lausanne.
Nota: O procedimento explicado aqui está voltado para a abordagem clássica executada para adenomas da hipófise.
1. pré-protocolo
<ol><li>Realize sistematicamente um pré-operatório craniofacial tomografia e ressonância, juntamente com as Avaliações oftalmológicas e endocrinológica.</li>
</ol>2. posicionamento ...

<ol>
	<li>Carrau, R. L., Jho, H. D., Ko, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transnasal-transsphenoidal+endoscopic+surgery+of+the+pituitary+gland.">Transnasal-transsphenoidal endoscopic surgery of the pituitary gland.</a> Laryngoscope. 106 (7), 914-918 (1996).</li><li>Kassam, A. B., Gardner, P., Snyderman, C., Mintz, A., Carrau, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Expanded+endonasal+approach:+fully+endoscopic,+completely+transnasal+approach+to+the+middle+third+of+the+clivus,+petrous+bone,+middle+cranial+fossa,+and+infratemporal+fossa.">Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa.</a> Neurosurg Focus. 19 (1), E6 (2005).</li><li>Jouanneau, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+endoscopic+endonasal+approach+to+the+Meckel's+cave+tumors:+surgical+technique+and+indications.">The endoscopic endonasal approach to the Meckel's cave tumors: surgical technique and indications.</a> World Neurosurg. 82 (6 Suppl), S155-S161 (2014).</li><li>Essayed, W. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+endonasal+approach+to+the+ventral+brainstem:+anatomical+feasibility+and+surgical+limitations.">Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations.</a> J Neurosurg. , 1-8 (2017).</li><li>Messerer, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extended+endoscopic+endonasal+approach+to+clival+and+paraclival+tumors:+Indications+and+limits.">Extended endoscopic endonasal approach to clival and paraclival tumors: Indications and limits.</a> Neurochirurgie. 62 (3), 136-145 (2016).</li><li>Rotenberg, B., Tam, S., Ryu, W. H., Duggal, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microscopic+versus+endoscopic+pituitary+surgery:+a+systematic+review.">Microscopic versus endoscopic pituitary surgery: a systematic review.</a> Laryngoscope. 120 (7), 1292-1297 (2010).</li><li>Zaidi, H. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+outcomes+between+a+less+experienced+surgeon+using+a+fully+endoscopic+technique+and+a+very+experienced+surgeon+using+a+microscopic+transsphenoidal+technique+for+pituitary+adenoma.">Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma.</a> J Neurosurg. 124 (3), 596-604 (2016).</li><li>Juraschka, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+endonasal+transsphenoidal+approach+to+large+and+giant+pituitary+adenomas:+institutional+experience+and+predictors+of+extent+of+resection.">Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection.</a> J Neurosurg. 121 (1), 75-83 (2014).</li><li>Pratheesh, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+current+role+of+transcranial+surgery+in+the+management+of+pituitary+adenomas.">The current role of transcranial surgery in the management of pituitary adenomas.</a> Pituitary. 16 (4), 419-434 (2013).</li><li>Messerer, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evidence+of+improved+surgical+outcome+following+endoscopy+for+nonfunctioning+pituitary+adenoma+removal.">Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal.</a> Neurosurg Focus. 30 (4), E11 (2011).</li><li>Zoli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cavernous+sinus+invasion+by+pituitary+adenomas:+role+of+endoscopic+endonasal+surgery.">Cavernous sinus invasion by pituitary adenomas: role of endoscopic endonasal surgery.</a> J Neurosurg Sci. 60 (4), 485-494 (2016).</li><li>Hamid, O., El Fiky, L., Hassan, O., Kotb, A., El Fiky, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomic+Variations+of+the+Sphenoid+Sinus+and+Their+Impact+on+Trans-sphenoid+Pituitary+Surgery.">Anatomic Variations of the Sphenoid Sinus and Their Impact on Trans-sphenoid Pituitary Surgery.</a> Skull Base. 18 (1), 9-15 (2008).</li><li>Frank, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+endoscopic+extended+transsphenoidal+approach+for+craniopharyngiomas.">The endoscopic extended transsphenoidal approach for craniopharyngiomas.</a> Neurosurgery. 59 (1 Suppl 1), ONS75-ONS83 (2006).</li><li>Cossu, G., Daniel, R. T., Leviver, M., Sykiotis, G., Messerer, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pituitary+metastasis+and+the+role+of+CSF+pulsations+in+secondary+displacement+after+surgery.">Pituitary metastasis and the role of CSF pulsations in secondary displacement after surgery.</a> Journal of Neurology and Neurosurgery. 3 (2), (2016).</li><li>Tarabay, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+pituitary+lymphoma:+an+update+of+the+literature.">Primary pituitary lymphoma: an update of the literature.</a> J Neurooncol. 130 (3), 383-395 (2016).</li><li>Dehdashti, A. R., Karabatsou, K., Ganna, A., Witterick, I., Gentili, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Expanded+endoscopic+endonasal+approach+for+treatment+of+clival+chordomas:+early+results+in+12+patients.">Expanded endoscopic endonasal approach for treatment of clival chordomas: early results in 12 patients.</a> Neurosurgery. 63 (2), 299-307 (2008).</li><li>Alfieri, A., Jho, H. D., Tschabitscher, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+endonasal+approach+to+the+ventral+cranio-cervical+junction:+anatomical+study.">Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study.</a> Acta Neurochir (Wien). 144 (3), 219-225 (2002).</li><li>Trouillas, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+prognostic+clinicopathological+classification+of+pituitary+adenomas:+a+multicentric+case-control+study+of+410+patients+with+8+years+post-operative+follow-up.">A new prognostic clinicopathological classification of pituitary adenomas: a multicentric case-control study of 410 patients with 8 years post-operative follow-up.</a> Acta Neuropathol. 126 (1), 123-135 (2013).</li><li>Kuo, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congress+of+Neurological+Surgeons+Systematic+Review+and+Evidence-Based+Guideline+on+Surgical+Techniques+and+Technologies+for+the+Management+of+Patients+With+Nonfunctioning+Pituitary+Adenomas.">Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Surgical Techniques and Technologies for the Management of Patients With Nonfunctioning Pituitary Adenomas.</a> Neurosurgery. 79 (4), E536-E538 (2016).</li><li>Lucas, J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congress+of+Neurological+Surgeons+Systematic+Review+and+Evidence-Based+Guideline+on+Primary+Management+of+Patients+With+Nonfunctioning+Pituitary+Adenomas.">Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Primary Management of Patients With Nonfunctioning Pituitary Adenomas.</a> Neurosurgery. 79 (4), E533-E535 (2016).</li><li>Teixeira, M., Souteiro, P., Carvalho, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prolactinoma+management:+predictors+of+remission+and+recurrence+after+dopamine+agonists+withdrawal.">Prolactinoma management: predictors of remission and recurrence after dopamine agonists withdrawal.</a> Pituitary. , (2017).</li><li>Cappabianca, P., de Divitiis, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopy+and+transsphenoidal+surgery.">Endoscopy and transsphenoidal surgery.</a> Neurosurgery. 54 (5), 1043-1048 (2004).</li><li>Jho, H. D., Carrau, R. L., Ko, Y., Daly, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+pituitary+surgery:+an+early+experience.">Endoscopic pituitary surgery: an early experience.</a> Surg Neurol. 47 (3), 213-222 (1997).</li><li>Borg, A., Kirkman, M. A., Choi, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+Endonasal+Anterior+Skull+Base+Surgery:+A+Systematic+Review+of+Complications+During+the+Past+65+Years.">Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years.</a> World Neurosurg. 95, 383-391 (2016).</li><li>Buchfelder, M., Schlaffer, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Techniques+in+the+Surgical+Treatment+of+Acromegaly:+Applications+and+Efficacy.">Novel Techniques in the Surgical Treatment of Acromegaly: Applications and Efficacy.</a> Neuroendocrinology. 103 (1), 32-41 (2016).</li><li>Shirakawa, M., Yoshimura, S., Yamada, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+Endoscopic+Endonasal+Transsphenoidal+Surgery+Using+a+Neuronavigation:+Clinical+Results+of+178+Pituitary+Adenomas.">Effectiveness of Endoscopic Endonasal Transsphenoidal Surgery Using a Neuronavigation: Clinical Results of 178 Pituitary Adenomas.</a> Journal of Neurology and Neuroscience. 7 (1:71), (2016).</li><li>Dehdashti, A. R., Ganna, A., Karabatsou, K., Gentili, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pure+endoscopic+endonasal+approach+for+pituitary+adenomas:+early+surgical+results+in+200+patients+and+comparison+with+previous+microsurgical+series.">Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series.</a> Neurosurgery. 62 (5), 1006-1015 (2008).</li><li>Starnoni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+acromegaly+according+to+the+2010+remission+criteria:+systematic+review+and+meta-analysis.">Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis.</a> Acta Neurochir (Wien). 158 (11), 2109-2121 (2016).</li><li>Alahmadi, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+technique+on+cushing+disease+outcome+using+strict+remission+criteria.">Impact of technique on cushing disease outcome using strict remission criteria.</a> Can J Neurol Sci. 40 (3), 334-341 (2013).</li><li>Donegan, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+Outcomes+of+Prolactinomas+in+Recent+Era:+Results+of+a+Heterogenous+Group.">Surgical Outcomes of Prolactinomas in Recent Era: Results of a Heterogenous Group.</a> Endocr Pract. 23 (1), 37-45 (2017).</li><li>Andereggen, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=10-year+follow-up+study+comparing+primary+medical+vs.+surgical+therapy+in+women+with+prolactinomas.">10-year follow-up study comparing primary medical vs. surgical therapy in women with prolactinomas.</a> Endocrine. 55 (1), 223-230 (2017).</li><li>Onnestam, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+incidence+and+prevalence+of+TSH-secreting+pituitary+adenomas+in+Sweden.">National incidence and prevalence of TSH-secreting pituitary adenomas in Sweden.</a> J Clin Endocrinol Metab. 98 (2), 626-635 (2013).</li><li>Malchiodi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thyrotropin-secreting+pituitary+adenomas:+outcome+of+pituitary+surgery+and+irradiation.">Thyrotropin-secreting pituitary adenomas: outcome of pituitary surgery and irradiation.</a> J Clin Endocrinol Metab. 99 (6), 2069-2076 (2014).</li><li>Yamada, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinicopathological+characteristics+and+therapeutic+outcomes+in+thyrotropin-secreting+pituitary+adenomas:+a+single-center+study+of+90+cases.">Clinicopathological characteristics and therapeutic outcomes in thyrotropin-secreting pituitary adenomas: a single-center study of 90 cases.</a> J Neurosurg. 121 (6), 1462-1473 (2014).</li></ol>

Para a maioria dos tumores da hipófise, cirurgia permanece o tratamento de primeira linha no caso de pacientes sintomáticos19,20. Somente para a prolactina (PRL)-segregar os adenomas, a primeira linha de tratamento é agonistas da dopamina e cirurgia é escolhida secundariamente quando o tratamento médico falha21.
Desde a introdução do endoscópio no campo da cirurgia de base de crânio no início dos anos ...

A introdução de técnicas endoscópicas para a cirurgia de base de crânio marcadamente melhorou os resultados da cirurgia de base de crânio quando usado em si mesmo ou como um complemento para abordagens microcirúrgicos padrão. A abordagem endoscópica endonasal foi introduzida inicialmente para tratar lesões sellar1, mas durante as últimas duas décadas as aplicações desta técnica têm expandido graças a avanços tecnológicos significativos e aumento da experiência cirúrgica . A abordagem endoscópica agora é também usada para lesões de base através de abordagens de linha média e paramediana estendidas do crânio anterior e ântero-lateral. Abordagens da base do crânio anterior para o odontoide são agora realizada com segurança em muitos centros especializados com satisfação resultados2,3,4,5.
Na verdade, o endoscópio permite uma visualização direta da lesão através de um acesso natural sem cruzar importantes estruturas neuro-vasculares. Vários clientes têm sustentado a segurança e vantagens relativas de procedimentos endoscópicos sobre abordagens tradicionais de microscópio e afirmou que os principais resultados, tais como a extensão da ressecção do tumor e as mudanças nos níveis hormonais, não eram diferentes entre as duas abordagens. Complicações neurológicas no entanto, tempo operatório e comprimento de internação, bem como desconforto pós-operatório dos pacientes, foram significativamente mais baixo com a abordagem endoscópica6. De acordo com uma publicação provocante, até um cirurgião menos experiente pode conseguir um resultado semelhante com uma técnica endoscópica totalmente como muito experiente cirurgião usando uma técnica microscópica em uma coorte de não-funcionamento adenomas da hipófise7.
A abordagem trans-esfenoidal endoscópica endonasal é na verdade amplamente recomendada para lesões sellar, mesmo em caso de invasão do seio cavernoso ou extensão supra-selar. Se a extensão supra-selar é muito importante, um procedimento de duas-encenado totalmente endoscópica pode ser realizado, enquanto aguarda a descida natural do resíduo8. Se o diafragma está muito apertado ("sinal de cintura"), uma abordagem transcraniana pode ser realizada para abordar o de componente supra-selar9. No que se refere a invasão do seio cavernoso, a técnica endoscópica parece ser superior às técnicas microscópicas para Knosp grau 2 e 3 não-funcionamento adenomas da hipófise10, e a inspeção endoscópica endonasal pode ajudar a detectar o invasão do seio cavernoso-11.
São fatores que podem dificultar uma excisão radical endoscópica: tumores estendendo acima e lateral à artéria interna de supraclinoid ou a presença de "beijando carótidas", uma extensão subfrontal assimétrica, tumores atingindo o forame de Monro ou fibrosos tumores invadindo o parênquima cerebral circundante9. Nestes casos complicados, poderá propor uma abordagem transcraniana combinada ao paciente. Também a pneumatização do seio esfenoidal é um fator importante na determinação da viabilidade da cirurgia porque seios tipo conchal processam a abordagem endoscópica mais desafiador12.
Através da sua experiência pessoal de aproximadamente 500 endoscópica endonasal abordagens para os adenomas da hipófise, os autores aqui descrevem os diferentes estágios da abordagem para tumores da hipófise. A cirurgia pode ser dividida em três etapas principais: a nasal, o esfenoidal e a fase sellar. Eles são realizados através de um procedimento totalmente endoscópico. A coorte descrita aqui incluídos pacientes com micro ou macro-adenomas com uma extensão variável para o seio cavernoso, o Seio esfenoidal, ou o espaço supra-selar. Os adenomas funcionais e não-funcionamento foram incluídos.
Um procedimento totalmente endoscópico pode ser realizado também para uma variedade de outras lesões como meningiomas petro-clival, metástases na hipófise, clival chordomas ou craniopharyngiomas. No entanto, estas patologias frequentemente necessárias abordagens mais amplas e a descrição dessas variantes ultrapassa o objetivo deste trabalho.
Indicação
O procedimento descrito aqui é para os adenomas da hipófise (funcionamento ou não funcionamento). Uma extensão supra-selar não foi uma contra-indicação para o procedimento, nem foram a extensão ou a invasão do seio cavernoso. A pneumatização do seio esfenoidal e a orientação dos septos do seio esfenoidal foram analisadas para o pré-operatório CT-scan. Também a orientação do nervo óptico e artéria carótida interna foram fatores importantes para planejar a estratégia cirúrgica.
Esta técnica cirúrgica também pode ser útil para outros tumores localizados na região sellar como craniopharyngiomas13, fissuras cistos sintomáticos de Rathke, metástases na hipófise14ou linfomas15. Além disso, outras lesões podem ser abordados através da abordagem endoscópica, como meningiomas do diafragma sellar ou o planum esfenoidal, meningiomas da região de petro-clival e clival chordomas5,16e epidermoide ou cistos dermoides da cisterna da prepontine. Nestes casos, no entanto, é necessária uma abordagem mais ampla.

<table>
	<tbody>
		<tr>
			<td>The StealthStation surgical navigation system</td>
			<td>Medtronic</td>
			<td>ENT Fusion Software 9733652</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 0&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132AA</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 30&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132BVA</td>
			<td></td>
		</tr>
		<tr>
			<td>4-mm 18cm 45&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>28132FVA</td>
			<td></td>
		</tr>
		<tr>
			<td>Suction Tube</td>
			<td>Karl Storz</td>
			<td>28164XA</td>
			<td></td>
		</tr>
		<tr>
			<td>Coagulation Cannulas</td>
			<td>Karl Storz</td>
			<td>28164MXB</td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar Forceps</td>
			<td>Karl Storz</td>
			<td>28164BDB</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKA</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKB</td>
			<td></td>
		</tr>
		<tr>
			<td>Kerrison Bone Punches</td>
			<td>Karl Storz</td>
			<td>28164MKC</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RO</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RI</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164RG</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164GLL</td>
			<td></td>
		</tr>
		<tr>
			<td>Ring Curettes</td>
			<td>Karl Storz</td>
			<td>28164GLR</td>
			<td></td>
		</tr>
		<tr>
			<td>de DIVITIS-CAPPABIANCA Scalpels</td>
			<td>Karl Storz</td>
			<td>28164M</td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td>Karl Storz</td>
			<td>28164TD</td>
			<td></td>
		</tr>
		<tr>
			<td>High-speed drill</td>
			<td>Midas Rex Medtronic</td>
			<td>1898430</td>
			<td></td>
		</tr>
		<tr>
			<td>Hemostatic agent</td>
			<td>Floseal, Baxter</td>
			<td>1503350</td>
			<td></td>
		</tr>
		<tr>
			<td>Fibrin sealant</td>
			<td>Tisseel, Baxter</td>
			<td>600065</td>
			<td></td>
		</tr>
		<tr>
			<td>CT Lightspeed</td>
			<td>GE medical systems, Milwaukee, WI, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Carestream Vue PACS</td>
			<td>Carestream Health, Rochester, NY, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>3-Tesla Siemens Tim Trio scanner</td>
			<td>Siemens AG, Erlangen, Germany</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas

Trans-esfenoidal cirurgia endonasal endoscópica tornou-se o padrão ouro para o tratamento cirúrgico de adenomas na hipófise e muitas outras lesões da hipófise. Refinamentos em técnicas cirúrgicas, os avanços tecnológicos e a incorporação de neuronavigation tem processado essa cirurgia minimamente invasiva. As taxas de complicação desta cirurgia são muito baixas, enquanto excelentes resultados consistentemente são obtidos através desta abordagem.
Este artigo enfoca a abordagem cirúrgica passo a passo para os adenomas da hipófise, que é baseada na experiência pessoal e detalha os resultados obtidos com esta cirurgia minimamente invasiva.

Desde 2009, o nosso programa na hipófise evoluiu a um ponto onde uma abordagem totalmente endoscópica endonasal tem sido usada para tratar tumores da hipófise, com excelentes resultados no pós-operatório. De 2009 a 2016, os dois cirurgiões sênior (RTD e MM) operado 473 pacientes com adenomas da hipófise através de uma técnica endoscópica completa. A histologia é detalhada na tabela 1: a maioria destes casos foram não-funcionamento adenomas da hipófise (57%) ...

Watch this Scientific Journal Video about Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas at JoVE.com

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

O objetivo deste trabalho é descrever as diferentes etapas da abordagem endoscópica endonasal para a Sela túrcica.

Abordagem endoscópica Endonasal Trans-esfenoidal: Cirurgia minimamente invasiva para Adenomas da hipófise

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary ...

The overall goal of this surgical intervention is to achieve a gross total removal of a pituitary adenoma through an endoscopic transnasal approach. The surgical technique facilitates the total removal of pituitary tumors to normalize hormone levels in separating tumors and to relieve visual and oculomotor symptoms in nonsecreting tumors. The main advantage of this technique is that it is minimally invasive while allowing maximum tumor resection, primarily due to the panoramic view that is provided by the endoscope.There may be a learning curve for using the endoscope techniques for neuro-surgeons who have been primarily trained to perform with a microscope. After general anesthesia and oral tracheal intubation, with the patient in the supine position, position the head in a head holder and secure the band for the magnetic neuro navigation around the head. Identification of the sellar anatomy using known and landmarks, that's also confirmed by the neuro navigation, allows the tumor to be accessed within the sellar, the suprasellar cisterns, and the cavernous sinuses bilaterally.Raise the head of the table to a 20 degree angle to improve the venous drainage. And slightly rotate the head about 30 degrees away from the side of the nasal fossa of interest while tilting the head in a contralateral direction. Sterilize the face with an alcohol-free chlorhexidine solution.And clean the nasal fosse with an antiseptic solution. Wick away the antiseptic with a cotton pad soaked in Xylocaine supplemented with one percent adrenaline. Then clean the right abdominal quadrants and drape the abdomen, leaving a small window in the right periumbilical region.When the patient is ready, introduce a short, rigid, zero degree endoscope into the right nostril to identify the inferior and middle turbinates laterally and the nasal septum medially. Place the endoscope tube either at the superior or inferior aspect of the nostril to provide enough space for other instruments entering the nasal cavity. Then, use a blunt spatula to gently and laterally retract the middle and superior turbinates to achieve a wide access to the ipsilateral sphenoid ostium.To avoid bleeding from the nasal septal arteries, place a monopolar between the sphenoid ostium and the choanae to coagulate the nasal mucosa in vertical linear direction for about ten to fifteen milliliters. Next, use the blunt spatula to vertically open the coagulated nasal mucosa until a bony contact is felt. Follow the vomer anteriorly until it's junction with the nasal cartilaginous septum and push the mucosa to the contralateral sphenoid ostium.Using bone forceps and a rongeur, expose and remove the sphenoid rostrum, extending the resection from one ostium to the other and exposing the exo cranial skull based surface. Gently remove the sphenoid mucosa if it interferes with the sellar opening. And use rongeurs to remove the sphenoid septum to provide a wide exposure of the sella turcica.Identify the sella turcica anterior and superior to the clival recess in the midline and the lateral carotid prominences. Using a five milliliter large bone cutter, open the sellar floor to create a bone flap that may be repositioned at the end of the surgery. Then enlarge the sellar osteotomy laterally or anteriorly with bone rongeurs, according to the surgical target.Use a micro-blade to open the selladurai as appropriate for the surgical target. And extend the dural open laterally as necessary, taking care to avoid any injury to the carotid arteries. This provides sufficient access to the sellar.Using anular angled curets, forceps, and suction tips, remove the tumor tissue. After an intrasellar saline wash out, use a 30 degree angled endoscope to inspect the intrasellar space for any tumor remnants, particularly toward the cavernous sinuses. After removing the tumor from the sellar and the suprasellar cistern, it is essential to use 30 degree endoscope to visualize the tumor within the cavernous sinuses bilaterally.If all of the tumor tissue has been removed, use saline irrigation and slight pressure with cotton pads to achieve hemostasis within the pituitary sella. Place a patch of bioabsorbable artificial dural substitute extradurally and reinforce the patch with a thin layer of surgical adhesive to reconstruct the durotomy. Replace the bone flap and secure it with more surgical adhesive.Then confirm hemostasis of the nasal mucosa, particularly in the region of the naso central branches of the sphenopalatine arteries on both sides to prevent post operative epistaxis. And gently replace the superior and middle turbinates, in their original position, with a blunt spatula. Since 2009, this fully endoscopic, endonasal approach has been used to treat pituitary tumors with excellent post operative results on 473 patients with pituitary adenomas.Most of the cases were non-functioning pituitary adenomas, followed by growth hormone secreting adenoma, and adrenocorticotropic hormone secreting adenomas. A total resection was achieved in 80 percent of patients with non-functioning pituitary tumors. Further, 30 to 100 percent of the patients who have undergone this procedure have demonstrated post operative chronological remission for up to seven years of follow up, depending on the type of tumor that was resected.Once mastered, this technique can be completed in two hours, if it's preformed properly. While attempting this procedure, it's important to remember that good outcomes will depend on the precise understanding of the anatomy of the tumor in relationship to the rental skull base as viewed through an endoscope. After sufficient experience with the endoscope surgery of sellar tumors, this technique can also be extended to other under nasal approach like or clever cardoma surgery.Don't forget that mastery of this technique requires practice in cadaver lab as well as many years of experience with surgery in live patients.

Research

JoVE Journal

Neuroscience

Minimally-invasive Technique for Injection into Rat Optic Nerve

Técnica minimamente invasiva para a injeção em Rat Optic Nerve

The rat optic nerve is a useful model for stem cell regeneration research. Direct injection into the rat optic nerve allows delivery into the central ...

Neurociência

Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons

Injecções intramusculares Ao longo das placas Motor End: uma abordagem minimamente invasiva para Shuttle Tracers Diretamente em Neurônios Motores

Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the ...

Effects of Transcranial Alternating Current Stimulation on the Primary Motor Cortex by Online Combined Approach with Transcranial Magnetic Stimulation

Efeitos da estimulação da corrente alternada transcraniana no córtex Motor primário por on-line abordagem combinada com estimulação magnética transcraniana

Transcranial Alternating Current Stimulation (tACS) is a neuromodulatory technique able to act through sinusoidal electrical waveforms in a specific ...

Healthy Brain-pituitary Slices for Electrophysiological Investigations of Pituitary Cells in Teleost Fish

Fatias de cérebro-hipófise saudáveis para investigações eletrofisiológicas das células da hipófise em peixes teleósteos

Electrophysiological investigations of pituitary cells have been conducted in numerous vertebrate species, but very few in teleost fish. Among these, the ...

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Evacuação de hemorragia intracerebral endoscópica minimamente invasiva

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Técnica de lesão minimamente invasiva para músculos intrínsecos ao Odontophore de Aplysia californica

Aplysia californica is a model system for studying the neural control of learning and behavior. This animal has a semi-open circulatory system, making it ...

Statistical Modelling of Cortical Connectivity Using Non-invasive Electroencephalograms

Modelagem estatística da conectividade cortical usando eletroencefalogramas não invasivos

Non-invasive electrophysiological recordings are useful for the evaluation of nervous system function. These techniques are inexpensive, fast, replicable, ...

A Revised Surgical Approach to Induce Endolymphatic Hydrops in the Guinea Pig

Uma abordagem cirúrgica revisada para induzir hidrops endoglicêsticos na Cobaia

Endolymphatic hydrops is an enlargement of scala media that is most often associated with Meniere&#39;s disease, though the pathophysiologic mechanism(s) ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Papel da Ramografia de Ressonância Magnética em Cirurgia de Base do Crânio Endonasal Endoscópica

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...

A Minimally Invasive, Fast Spinal Cord Lateral Hemisection Technique for Modeling Open Spinal Cord Injuries in Rats

Técnica Minimamente Invasiva e Rápida de Hemisecção Lateral da Medula Espinhal para Modelagem de Lesões Medulares Abertas em Ratos

Open spinal cord injury techniques modeling laceration-like injuries are time-consuming and invasive because they involve laminectomy. This new technique ...